Management of Psychodermatologic Disorders

Philip D. Shenefelt, MD, MS


Dermatology Nursing 

In This Article

Psychiatric Disorders Secondary to Skin Diseases

About 30% of patients who have skin disorders are reported to have psychiatric disorders and psychosocial impairments (Kessler et al., 2005). The prevalence of psychological disorders among patients with skin disease is about 25%-30%, with higher rates of over 30% among patients with acne, pruritus, urticaria, alopecia, and herpes simplex (Picardi, Abenia, Melchi, Puddu, & Pasquini, 2000). Psychological morbidity in addition to skin disease is associated with poorer quality of life (Sampogna et al., 2004).


In anxiety-prone individuals acne can increase anxiety substantially. Acne can worsen problems with self-esteem, self-confidence, embarrassment, and impaired social functioning. Stress and anxiety can in turn cause acne to flare, creating a vicious circle (Schulpis, Georgala, Papakonstantinou, & Michas, 1999). Drug treatment choices for anxiety include low-dose benzodiazepine, buspirone, or herbal treatments such as magnolia bark or passion flower. Reassurance and coaching relaxation techniques or self-hypnosis for relaxation can assist treatment of anxiety. Pruritus from hives and release of histamine can induce anxiety in anxiety-prone individuals. Anxiety can then aggravate the urticaria, creating a vicious circle (Arck & Paus, 2006). Hydroxyzine (Atarax®) and doxepin (Sinequan®) cause sedation and can reduce anxiety while also reducing the urticaria through their antihistaminic effect.


Depression can occur or be exacerbated by any of several common skin diseases. Acne most commonly begins in adolescence, which is a particularly vulnerable time emotionally. Those with severe acne had a prevalence of depression of about 18%-29%, compared with a prevalence of depression of about 5%-8% for the general adolescent population (Hull & D'Arcy, 2005). Depressive symptoms in adolescents are often concealed or denied or expressed through aggressive or disruptive behavior. The drug isotretinoin (Accutane®) used to treat nodulocystic acne has been weakly associated with depression and suicide (Wysowski, Pitts, & Beitz, 2001).

Alopecia has an impact on psychosocial functioning, and depression can be induced or exacerbated in susceptible individuals following hair loss. Alopecia areata can flare with depression (Hughes et al., 1983). Pruritus of atopic dermatitis can also aggravate depression, often causing increased scratching and worsening of their skin disorder (Gupta, Gupta, & Schork, 1994). Antihistamines hydroxyzine and doxepin can reduce pruritus and scratching through their antihistaminic effect. Doxepin also is a tricyclic antidepressant so it has a dual action. Disfigurement from skin disorders, traumatic injuries (Stoddard, Stroud, & Murphy, 1992), and surgeries for skin cancers can aggravate depression in depression-prone individuals. Having metastatic melanoma can induce situational depression, which in turn degrades the body's immune response (Herbert & Cohen, 1993) against the melanoma metastases.

The "heartbreak of psoriasis" can initiate or exacerbate depression in depression-prone individuals, which in turn can increase the pruritus (Gupta et al., 1994). Scratching pruritic psoriatic plaques can exacerbate the psoriasis as well as increase risk for infection because of disturbance of skin integrity. Another pruritic condition, chronic urticaria, can initiate or exacerbate depression in depression-prone individuals, which can in turn exacerbate pruritus (Gupta et al., 1994). Hypnosis has been curative of some cases of chronic urticaria (Shenefelt, 2007).

Vitiligo, especially in darkly pigmented individuals (Dogra & Kanawar, 2002), can initiate or exacerbate depression in depressionprone individuals. For each of these conditions, individuals with major depression should be referred to a psychiatrist for care. For minor depression, SSRIs or tricyclics may be prescribed by the dermatologist or primary care provider, or the herb St. John's wort may be recommended. Teaching the patient selfhypnosis as the author does in selected cases, can lessen pruritus and give a sense of greater control, which in turn can lessen the depression.


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